Urinary catheterization in Pediatrics

Urinary catheterization is the insertion of the catheter through the urethra into the bladder for withdrawal of urine.

Indications

• To obtain a urine specimen
• To relieve urinary retention
• To allow the bladder to restore or heal after a surgery
• To dilate a urethral stricture
• To decompress the bladder
• To measure residual urine
• In management of patients with spinal cord injury, neuromuscular degeneration, or incompetent bladder
• For diagnostic testing such as voiding cystourethrography or urodynamics

Short-term Indwelling Catheterization

• Post surgery and critically ill patients to monitor urinary output
• Surgical procedures involving pelvic or abdominal surgery
• Repair of bladder urethra and surrounding structures
• Urinary obstructions and acute urinary retention
• Prevention of urethral obstruction from blood clots with continuous or intermittent bladder irrigation
• Instillation of medications into the bladder

Long-term Indwelling Catheterization

• Refractory bladder outlet obstruction and neurogenic bladder with urinary retention
• Prolonged and chronic urinary retention
• To promote healing of perineal ulcer where urine may cause further skin breakdown

Equipment Needed

Catheterization tray consists of:

• Disposable sterile gloves
• Drapes
• One fenestrated
• One Non fenestrated
• Lubricant
• Cotton balls with container
• Two artery forceps
• Prefilled 10-cm’ syringe with sterile water to inflate the balloon
• Sterile specimen container for urine sample collection
• Sterile catheter of appropriate type and size
• Chlorhexidine 2% aqueous solution
• Sterile water
• Catheter secure device or adhesive tape
• Urinary drainage bag with tubing
• Medicated lubricant

Preparation of the Child and Parents

• A careful explanation of the procedure and its rationale is completed prior to catheterization. The explanation must be tailored to both the developmental level of the child and needs of the parents.
• For infants: Reassure the parents that the procedure will not cause pain and neither the bladder nor the urethra will be damaged.
• Toddlers and older children: Typically appreciate seeing and manipulating a nonsterile catheter in order to feel its softness and pliability for themselves. The child should be taught to relax the pelvic muscles prior to insertion of the catheter.
• For infants: Remain in a supine position and emphasis is placed on leaving the hips flat on the procedure table/bed
• For toddlers and young children: Teach to blow a pinwheel.
• For preschoolers and school aged: Teach to blow out and gently press the hips against the table. This maneuver is repeated as the catheter is inserted in order to avoid breath-holding and raising hips from the procedure table, which tightens the periurethral muscles and increases discomfort.
• Adolescents: Teach to isolate, contract, and relax the pelvic muscle prior to catheterization and to breathe, slowly and deeply as the tube is inserted

Note: Adolescent girls may prefer to be catheterized by a female staff and adolescent boys may prefer to be catheterized by a male caregiver. The request should be honored whenever feasible.

• Since catheterization typically provokes anxiety and discomfort, assistance and gentle restraint may be indicated.

Parents may be allowed to remain with the child during the procedure to both restrain and distract the child.

Catheter Selection for Urinary Catheterization

Choosing the appropriate catheter depending on:

• The size of the patient’s urethral canal
• Expected duration of catheterization
• Knowledge of any allergy to latex or plastic
• Indication for catheterization.
• Child’s age

Types

• Straight single-use catheters: Have a single lumen with a small 11/4-cm opening.
• Two-way Foley’s catheters (retention catheter): Have an inflatable balloon that encircles the tip near the lumen or opening of the catheter.
• Curved or coude catheters: Have a rounded curved tip.
• Three-way Foley’s catheter: Often called retention catheter. They have two or more lumens that encircle the body of catheter One lumen drains the urine through the catheter into a collection bag. The second lumen holds the sterile water when the catheter is inflated and is also used to deflate the balloon. The third lumen may be used to instill the medication into the bladder or provide a route for continuous bladder irrigation.

Special Considerations

• Myelodysplastic children may develop hypersensitive reactions, including anaphylaxis when exposed to latex products. So nonlatex catheter (silicon) and nonlatex sterile field are routinely used for these patients and careful documentation of latex allergy is recorded in the child’s chart.
• Artificial spincter: Meticulous aseptio technique is used. The urethral cuff is deflated immediately prior to catheter insertion.
• Epispadias or classic exstrophy: A Young-Dees-Leadbetter procedure is frequently performed to improve the continence. In this, the urethra is angulated with respect to the bladder base to improve continence and this acute angle makes catheterization a challenge.
• In boys with multiple catheterizations, congenital or acquired urethral strictures may be difficult to catheterize. In the above circumstances, a special preparation is needed:
• Select a smaller coude tipped catheter.
• Insert 5-10 mL of xylocaine lubricant into the urethra by using the gentle pressure.
• The urethra is filled until the child perceives pressure and the lubricant is held in place by occluding the meatus. This is to provide anesthesia of the urethra and encourage slight urethral opening prior to catheter insertion.
• Insert the catheter without allowing the lubricant to leak from the urethra.
• In rare instances, systemic sedation may be necessary prior to urethral catheterization.
• When reasonable efforts are failed, the procedure should be discontinued.
  Consult the pediatric urologist.
• Catheterization is completed using endoscopic guidance, urethral dilation, adequate sedation, or local anesthesia.

Procedure

• Gather appropriate equipment and place into a sterile field.
• Perform hand hygiene and don sterile gloves.

For female child

•  Place a sterile drape under buttocks.
• Gently separate and pull up the labia minora to visualize the meatus by using nondominant hand and hold the labia open throughout the procedure.
• Swab the meatus from the proximal to distal end using sterile povidone iodine-dipped swabs.
• Lubricate the catheter and insert it into the urethra until urine is obtained.
• Advance the catheter an additional 2.5-5 cm.
• Inflate the balloon with sterile water when using Foley’s catheter and gently pull back to test balloon inflation.
• Connect the Foley’s catheter to closed drainage system.
• Clean the meatus and labia of povidone iodine and wipe it with wet swab.
• Praise the child for cooperation.

For male child

• Grasp the penis with nondominant hand and retract the foreskin and should be remained throughout the procedure.
• Place the sterile drape under the penis.
• Using the sterile cotton swab, clean the glans and meatus with povidone iodine.
• Hold the penile shaft just under the glans to prevent the foreskin from contaminating the area.
• Lubricate and insert the catheter while gently stretching the penis and lifting it to 90° angle to the body.
• Resistance may occur when the catheter meets the urethral sphincter. Ask the child to inhale deeply and advance the catheter at that time.
• Once urine is obtained, advance the catheter to the hub of the catheter (indwelling catheter).
• For intermittent catheter, insert only up to recommended length.
• Inflate the balloon with the sterile water, pull it back gently to test inflation and connect it to the closed drainage system.
• Cleanse the glans and meatus with water to prevent skin irritation.
• Replace the retracted foreskin.

Note: If at any time during the procedure the blood is seen, discontinue the procedure and notify the pediatrician.

•  Secure the catheter to either patient’s thigh or abdomen. This helps to decrease the risk of bleeding trauma and bladder spasms from pressure and traction.

General Instructions

• If the child says that he/she needs to urinate during catheter insertion, tell the child to go ahead and try to do so. This opens the meatus for passage of the catheter.
• The rule of thumb for catheter length in males is twice the length of the penis plus
  4 cm.
• If the child complains of pain or burning, the urinary catheter may not be fully seated in the bladder. Deflate the balloon, advance the catheter further, and reinflate the balloon.
• Daily skin care is essential.
• Adequate fluid intake should be maintained.
• The urine collection bag should be emptied when one-half to two-thirds full or every 3-6 hours. This helps to prevent undue trauma/traction on the urethral related to weight of the bag
• The frequency of catheter changing should be individually tailored and may be needed every 3-4 weeks.

Instillation of lidocaine gel

•  Infant ½-1 ½ mL
• Toddler 1 ½-2 ½ mL
• School aged 2 ½-5mL
• Adolescent 3-5 mL.

Nursing Care of a Child with Indwelling Catheter

• Perform hand hygiene and gather necessary supplies.
• Close the door of the child’s room or draw curtains around the child’s bed.
• Raise bed to a comfortable working height,
• Don gloves.
• Place a waterproof pad/mackintosh under the child’s buttock while positioning the child.
• Girls should be in supine position with their legs spread apart. Boys should be placed in supine with legs straight.
• Place a drape over the child. For girls, place the drape in a diamond configuration with one corner at the child’s sternum, one corner over each knee, and one corner over child’s perineum. For boys, cover the child’s chest and lower extremities with a sheet leaving only the genital area exposed.
• Examine the urethral opening with the help of flashlight.
• Observe any signs of irritation, trauma, and secretions.
• With the use of syringe, deflate the balloon and assess the amount of water in it and reinflate it.
• Wash the child’s genital area with warm water and soap.
• Clean around the urinary meatus and around the catheter itself being careful not to manipulate the catheter. Gently retract the foreskin of boys and clean the area. Return the foreskin to its natural position.
• Rinse and dry the child’s perineum.
• Assess the drainage tubing for urine flow and observe that there are no kinks or obstruction in the tubing and make sure that all connections are tightly secured.
• Ensure the collection bag is attached to the frame of the bed below the level of the bladder.
• Ensure the catheter adheres to the thigh or lower abdomen.

Removal of the Indwelling Catheter

• Collaborate with the child’s family and health-care personnel regarding the time of removal of indwelling catheter.
• Perform hand hygiene and collect all necessary equipment for removal.
• Provide privacy.
• Raise the bed to a comfortable working height.
• Don gloves.
• Place mackintosh under the child’s buttocks while positioning the child. Position the child supine with the legs apart with access to the urinary catheter.
• Place a drape over the child
• Gently remove the tape holding the urinary catheter in place.
• Attach a syringe to the secondary lumen balloon port of the urinary catheter and deflate the balloon of its entire contents of sterile water.
• Gently remove the urinary catheter by withdrawing slowly and evenly if resistance is felt, do not pull harder, stop, and notify the physician.
• Wash the child’s genital area with warm water and soap. Rinse and dry the area.
• Remove the mackintosh and position the child comfortable.
• Lower the height of the bed to an appropriate level.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
5. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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